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How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

July 26, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page: 21-24 | Andreas Heinrich Hugo Tiemann[1], Ralf Herbert Gahr[2] . Author: Andreas Heinrich Hugo Tiemann[1], Ralf Herbert Gahr[2]. [1]SRH Zentralklinikum Suhl, Medical Director,Albert-Schweitzer-Str. 2 ,98527 Suhl. [2]Klinikum St. Georg Leipzig, Delitzscher Str. 141, 04129 Leipzig. Address of Correspondence Dr Ralf Herbert Gahr Klinikum St. Georg […]

Management Options and Treatment Algorithm in Intertrochanteric Fractures

July 26, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page: 12-16 | Anoop C Dhamangaonkar [1] Author: Anoop C Dhamangaonkar [1]. [1]Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Sion, Mumbai- 400022, India. Address of Correspondence Dr. Anoop C Dhamangaonkar 2/28,Madhavi Soc., Mogal Lane, Matunga (W), Mumbai-400016.India. Email: anoopd_7@yahoo.com Abstract Background: Intertrochanteric (IT) […]

How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

July 26, 2015/in July Sep | Volume 1 | Issue 1

Management Options and Treatment Algorithm in Intertrochanteric Fractures

July 26, 2015/in July Sep | Volume 1 | Issue 1

Full Sized Blog Element (Big Preview Pic)

How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

July 26, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page: 21-24 | Andreas Heinrich Hugo Tiemann[1], Ralf Herbert Gahr[2] .

Author: Andreas Heinrich Hugo Tiemann[1], Ralf Herbert Gahr[2].

[1]SRH Zentralklinikum Suhl, Medical Director,Albert-Schweitzer-Str. 2 ,98527 Suhl.
[2]Klinikum St. Georg Leipzig, Delitzscher Str. 141, 04129 Leipzig.

Address of Correspondence
Dr Ralf Herbert Gahr
Klinikum St. Georg Leipzig
Delitzscher Str. 141, 04129 Leipzig
Email: ralfgahr@sanktgeorg.de

Abstract

Background: Hip fractures belong to the most frequent fractures of elderly people. The treatment follows a specific algorithm that focuses on the medical as well as the social situation of these patients. Despite modern operative techniques and implants complications may occur. They may be distinguished into two groups: local complications and systemic complications
Especially local complications (cut out of the femoral head screw) are the reason for revision surgery. Surgery (“salvage procedures”) may only be performed after critical analysis of the local situation and individual planning of the revision procedure. This article outlines the tactical course of action in these cases.
Keywords: Hip fractures – complication – salvage procedure – therapeutic algorithm.

Introduction

Hip fractures are typical injuries of the elderly [1]. Recent studies prove that the incidence of these entities rises dramatically with increasing age [1]. In 2008 Lohmann et al. showed an incidence of 0.06 percent at an age between 60 and 64 years and an incidence of 1.3 percent at people at their eighties [2]. In other words: More than 90 percent of the patients are in their seventies and in addition more than 70 percent are females [3].
American authors assume, that the number of hip fractures will increase from 250,000 in the year 1990 up to 500,000 in 2040 [4]. In Germany the rate of hip fractures totals up to 90/100.000 inhabitants for all classes of age but is 966/100.000 for septuagenarians [5, 6]. Till 2050 the incidence is assumed to multiply by five [6].
In case of geriatric patients suffering from a hip fracture leads to a significant decrease of life expectancy accompanied by an increased medical risk and a number of social problems (for example accommodation in a retirement home) [7, 8]. Anglo-American analyses indicate an average reduction of life expectancy of 1.8 years or 25 percent of the remaining life span per patient [9]. The treatment of such injuries demands a specific algorithm that takes the local surgical problems and co-morbidities as well as social necessities into consideration. Highest goal of the surgical treatment is the early mobilization, prevention of secondary complications and the return to maximal autonomy. Hip fractures today are regularly treated by operative stabilization [10]. Nevertheless the ideal operative procedure is still discussed in the literature [11].
Even modern operative techniques and implants these procedures show adverse events or complications in 15 to 20 percent [12, 13]. Based on acuteness, topography and implant association they may be distinguished into the following groups [14]:
A. Acuteness
Early complication (within three months after surgery)
tactical surgical failure
technical surgical failure
local complication (like wound healing disturbance or infection)
systemic complications (like deep vein thrombosis)

Late complication (after more than three months postoperatively)
effect of poor bone biology (like delayed union or pseudarthrosis)
contracture

b.Topography
local complication (see above)
systemic complication (see above)

c. Implant association
implant associated complication (like cutout, peri-implant fracture or implant failure); (see below)
non implant associated complication

(Revision) Surgery: Planning and tactics
In reference to the special situation of aged patients one has to pay attention to two central factors no matter if one performs primary or revision surgery:
· short term operation
· full weight bearing possible after surgery
Thus the planning of surgery must be focused on the prevention of tactical and technical failures. Revision surgery necessary because of local complications may be divided into two groups:
· Implant (osteosynthesis) related procedures.
Planned implant replacement (for example progressive coxarthrosis that leads to removal of an intramedullary stabilization system in order to implant a total hip arthoplasty).
Enforced implant replacement based on local complications (salvage procedures)

Not implant related local surgery (like the relief of a local hematoma).
A strict separation between these two types of complications is not always possible in praxi. Based on the above named principles one has to keep in mind the following general standards [15]:
· On the part of the surgical procedure:
o full weight bearing possible after surgery
o stable implant fixation in osteoporotic bone
o preservation of the vascularization of the femoral neck and head
o simple operative technique

· On the part of the surgeon:
o profound knowledge of possible implants and surgical techniques
o mastery of the intramedullary and extramedullary surgical options as well as of arthroplasties
oclear Nevertheless the different studies still show different results indication for a specific implant.

Key-factor I: Preoperative analysis (Fig. 1 and 2)
Primary surgery as well as revision surgery demands a proper analysis of the local situation. The following questions have to be answered preoperatively [15]:
·Where is the problem localized (femoral head and/or femoral neck, trochanteric region, subtrochanteric)?
·Why did the complication occur?
·How may the problem be solved (reosteosynthesis versus (hemi) arthroplasty)?
·What is the correct implant?
·When is the optimal point in time for the operation?

Key-factor II: Osteosynthesis or arthroplasty (Fig. 3)?
In order to answer these questions the following factors are important:
Is the actual situation generally applicable to be treated with an osteosynthesis?
o from the part of the fracture
o from the part of the hip joint (i.e. presence of a significant symptomatic coxathrosis)
If the answer to this question is YES: Which technique will be performed?
o intramedullary stabilization
oextramedullary stabilization
If the answer to this question is NO: Which alternative technique should be performed (hemiarthroplasty, total arthroplasty) [16, 17, 18, 19]?

Stable fractures (AO/OTA 31-A1) present the classic indication for osteosynthesis. The cure rate is close to 100 percent [20]. These fractures mainly are stabilized by the use of a dynamic hip screw (DHS).
AO/OTA A31-A2 and –A3 are unstable fractures. The optimal treatment is still open to debate in the recent literature [16, 17]. Intramedullary stabilization is considered to be better in terms of biomechanical considerations [21]. Nevertheless osteosynthesis failure is estimated to be 56 percent [20].
The question whether to perform reosteosynthesis or switch to hip arthroplasty is elaborated just by few studies. The different studies show different results. Nevertheless Faldini 2002, Sinno 2007 and Giannotti 2013 and 2014 indicate, that elder patients suffering from those unstable pertrochanteric fractures benefit from treatment by cemented hemiarthoplasty. This leads to faster mobilization and lower mortality [16, 17, 18, 19]. According to D`Arrigo et al. the candidates for proximal femur replacement are patients with non-viable proximal femoral segments, destruction of the proximal femoral articular surface, advanced age and the absence of coxarthrosis [22]. Total arthroplasty may be taken into consideration in case of patients with additional severe coxarthrosis.
Switching from internal fixation to arthoplasty offers some special problems [22]:
· failed internal fixation (sometimes accompanied by broken screws) must be removed
· necessity of special instruments in order to remove the failed system
· compromised proximal femur with bone loss distal to the typical neck-resection level for hip arthroplasty

Key-factor III: Open or closed reduction (Table 1)?
The preoperative fracture analysis with a view to it`s reductive capacity based on the radiographic findings (X-ray, CT-scan) is an integral component as well for primary surgery as for revision surgery when reosteosynthesis seams to be possible. Open and closed reduction is the typical approach. Normally AO/OTA 31 fractures will be closed reduced. However between three and 17 percent are estimated to be applicative for closed reduction [23, 24, 25]. In their study Sharma et al. identified 4 general fracture situations, which are not applicative for closed reduction [25]:
· AO/OTA 31-A1 fractures where the proximal fragment is locked underneath the overridden and mediatized shaft fragment
· AO/OTA 31-A1 fractures with bisected lesser trochanter
· AO/OTA 31-A2 fractures with entrapment of the posteromedial fragment at the fracture site
· AO/OTA 31-A2 fractures with an anteriorly displaced proximal fragment and an underlying separate lesser trochanter
The mentioned AO/OTA 31-A1 fractures mainly occurred in younger, the AO/OTA 31-A2 fractures in older patients.

Implant related specification of typical complications of osteosynthesis
In case of planned (re-) osteosynthesis knowledge of the specific osteosynthesis related complications is vital in order to avoid local surgical complications. In general the complication rate is estimated to be three percent [26]. Sathiyakumar et al. distinguished five different treatment variant with significantly different typical implant related complications [9].
The complications mentioned below may occur after intramedullary stabilization as well as extramedullary stabilization of AO/OTA 31 fractures.

Particulars and choice of typical complications of extramedullary systems
The overall complication rate is estimated to be between 6.8 and 16.7 percent [27]. The rate of mechanical complications is estimated to be 2.8 percent [26].
Typical complications
· Cutout. Between three and 16.7 percent for dynamic hip screws [27, 28, 29].
· Z-effect. Mentioned below (intramedullary complications)
· Jamming of the lag screw. According to Simpson this is one of the main reasons for dynamic hip screw failure [30].
· Peri-implant fracture. Parker et al. found it in 0.1 percent in their 2010 study [27].
· Implant overload
· Implant dislocation

Particulars and choice of typical complications of intramedullary systems
The overall complication rate is estimated between 3.6 and 18 percent in the recent literature [26].
Typical complications
·Dislocation of the lesser trochanter
·Varus dislocation of the fracture
·Z-effect-A classical complication of two screw systems (like the proximal femoral nail). The repetitive axial loading of the implant combined with an unstable fracture fixation situation leads to toggling of the nail within the femoral canal [31]. This leads to medial migration of the nail. This mechanism is also described in the 2008 study of Weil et al. [32]. Nevertheless the precise etiology requires further clarification [33].
·Cutout. The Cochrane analysis of 2010 describes a rate of 3.4% for intramedullary implants [27]. The contemporary 2014 study of Greorgiannos evidences a rate between two and ten percent [34]. For intramedullary system as well as extramedullary ones the possibility of cutouts depends on the positioning of the lag or sliding screw in the proximal fragment [34]. As early as 1995 Baumgartner et al. described the so-called “tip-apex-distance” (TAD). This nowadays is accepted to be the central principle for the optimal positioning of the lag screw. It is determined intraoperative in the ap. and axial view fluoroscopy [35]. Kuzyk et al. showed in 2012 that the position of the lag screw next to the “Adam´s bow” in the ap. view and in the center of the proximal fragment in the axial view optimizes the biomechanical stability of the osteosynthesis [36]. In addition Nikoloski et al. could prove, that the original TAD rule should be modified depending on the used system, especially when “two screw systems” are used [37]. These authors distinguished two main types of cutout [37]:
o cephaled cutout
o axial cutout
· Knife effect
· Secondary screw dislocation
· Peri-implant fracture. Robinson et al. described an incidence of 18.74 fractures per 1000 person years in case of fractures treated with intramedullary systems [38]. The analysis of Parker et al. in 2010 showed an incidence of 2.6 percent [27]. By developing new designs of the intramedullary devices in the last decades the rate of these complication could be decreased dramatically.
· Implant failure

Discussion

Trochanteric femoral fractures comprise 50 percent of geriatric hip fractures. [39]. Although union rates as high as 100 percent have been reported after primary reduction and internal fixation with stable fractures ideal implants and optimal reduction failure rates over 50 percent are described in case of unstable fractures, suboptimal fracture fixation and poor bone quality [40]. Thus the correct individualized primary stabilization already presents a demanding problem. Appropriate management of failed primary osteosynthesis is even more challenging.
According to the recent literature the choice of treatment depends on the clear identification of the fracture type combined with the specific local situation [39]:
· AO/OTA classification of the fracture.
· radiographic analysis of the local bone structure
o presence or absence of osteoporosis
o presence or absence of extended bone loss
o presence or absence of significant coxarthrosis
When, based on the AO/OTA classification and the above-mentioned facts, the decision for internal (re-) fixation is made optimal reduction of the fracture fragments and positioning of the chosen implant is from central interest [35]. According to the recent literature implant failure generally seems to be the result of poor fracture reduction, mechanical stress, fracture instability or technical error [40] Although the optimal treatment for unstable fracture situations {AO/OTA 31-A2 and A3) are still discussed controversially in the last years a rising number of studies presents good results for arthroplasty as well for primary as for revision surgery [41,42]. Unfortunately there are only few comparative studies and even fewer prospective, random controlled ones which compare prosthetic hip replacement with the standard internal fixation in terms of primary and revision surgery [16]. In their 2014 study these authors come to the conclusion that there are no major differences between the treatment with hemi- or total arthroplasty but especially the elderly patients with severe osteoporosis or comminuted trochanteric fracture take significant profit from the treatment with hip arthroplasty compared to internal fixation [Giannotti]. According to Parker et al. in 2006 there are no significant differences between arthroplasty and internal fixation for mechanical complications, local wound complications, general complications and mortality at one year or long-term function [42].

Conclusion

· proximal hip fracture treatment is no trauma surgery for beginners
· local bone and fracture situation have to be clearly analyzed before taking one or the other surgical option into consideration
· primary stabilization as well as reoperations show specific pitfalls which may affect the outcome of any chosen treatment option significantly
· surgeons have to have profound knowledge about how to identify these pitfalls in order to avoid technical and tactical failure
especially in unstable fracture situations and in case of failed primary internal stabilization arthroplastic treatment should be a serious alternative.

References

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29. Huseh KK et al. Risk factors in cutout of sliding hip screws in intertrochanteric fractures: an evaluation of 937 patients. Int Orthop 2010; 34(8): 1273 – 1276
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32.Weil YA, Gardner MJ, Mikhail G, Pierson G, Helfet DL, Lorich DG. Medial migration of intramedullary hip fixation devices: a biomechanical analysis. Arch Orthop Trauma Surg. 2008 Feb;128(2):227-34.
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36. Kuzyk PR, Zdero R, Shah S, Olsen M, Waddell JP, Schemitsch EH. Femoral head lag screw position for cephalomedullary nails: a biomechanical analysis. J Orthop Trauma. 2012 Jul;26(7):414-21.
37. Nikoloski AN, Osbrough AL, Yates PJ. Should the tip-apex distance (TAD) rule be modified for the proximal femoral nail antirotation (PFNA)? A retrospective study. J Orthop Surg Res. 2013 Oct 17;8:35.
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How to Cite this article: Tiemann A H H, Gahr R H. How to Avoid local Complications during primary and revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting. Trauma International July-Sep 2015;1(1):21-24.

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Management Options and Treatment Algorithm in Intertrochanteric Fractures

July 26, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page: 12-16 | Anoop C Dhamangaonkar [1]

Author: Anoop C Dhamangaonkar [1].

[1]Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital,
Sion, Mumbai- 400022, India.

Address of Correspondence
Dr. Anoop C Dhamangaonkar
2/28,Madhavi Soc., Mogal Lane, Matunga (W), Mumbai-400016.India.
Email: anoopd_7@yahoo.com

Abstract

Background: Intertrochanteric (IT) fractures are one of the most common lower limb fractures. There are many varied treatment options to treat the same. Also, our basic understanding of IT fractures is improving leading to evolution of newer concepts which in turn is leading to designing of newer implants. In this sea of newer treatment options, are all newer implants merely market driven? The new- age orthopaedic surgeon needs to be made aware of the newer concepts of IT fractures, implant designs and also a comprehensive literature support of the various treatment options available like concept of unstable IT farcture, the dynamic hip screw (DHS) system, Medoff’s plate, DHS with a trochanteric stabilization plate, 95 degree Dynamic Condylar Screw, first to third generations of gamma nails, proximal femoral nails (PFN), expandable PFN, InterTAN with integrated interlocking screws, proximal femoral locking plates and use of bipolar hemiarthroplasty. This article also aims to present a practical treatment algorithm for the treatment of IT fractures, but this may not be generalizable to all orthopaedic surgeons.
Keywords: Intertrochanteric; unstable; DHS; PFN; Gamma; hemiarthroplasty.

Introduction

Intertrochanteric (IT) fractures are disabling injuries that most commonly affect the elderly population and also in young. The incidence has increased significantly during recent years due to the advancing age of the world’s population. These fractures were managed by conservative methods before 1930s when the age of fixation began. Through this article we wish to present the gradual yet sudden transition in various treatment modalities.
Till the third decade of the twentieth century trochanteric fractures were treated conservatively. Conservative treatment regimes included, simple support with pillows or splinting to the opposite limb, Buck’s (skin) traction, Well-leg traction, plaster spica immobilization, Russell’s balanced traction and skeletal traction through the lower femur or upper tibia. Nonsurgical treatment of intertrochanteric hip fractures is not preferred but is usually reserved for patients with comorbidities who are not fit for anesthesia. Mortality after non-operative treatment is commonly due to cardiopulmonary complications, thromboembolism, and sepsis [1]. In 1989, Hornby et al compared the nonsurgical treatment with a dynamic hip screw (DHS) in 106 patients with intertrochanteric hip fracture [2]. There was no significant difference in complications, 6-month mortality, pain, leg swelling, or pressure sores. SHS group gave better anatomic reduction and a shorter hospital stay. Patients treated conservatively had greater loss of independence at 6-month follow-up. The authors recommended surgical treatment for medically stable patients. A 1981 prospective trial of 150 patients compared nonsurgical treatment (ie, skeletal traction with a tibial pin) with surgical treatment [3]. The authors concluded that excellent results with traction alone could be obtained provided a good nursing care was maintained with careful attention to bedside physical therapy, respiratory care, deep vein thrombosis prophylaxis, and prevention of ulcers. A 2003 retrospective study reviewed a population database to compare mortality rates in patients with severe comorbidities who were treated either nonsurgically or surgically for intertrochanteric hip fracture [4]. It concluded that the mortality rate was low in the conservatively treated patients provided the patients were mobilized early out of bed to chair. The evidence-based literature supports surgical fixation while also providing valuable information in regard to medically unstable patients who must be treated nonsurgically [2-4].

Operative treatment options
Era of Dynamic Hip Screw (DHS)
During the early 1950s when the use of Smith Peterson nail and Jewett nail-plate was very common, W. Schumpelick et al. revolutionized treatment of IT fractures by presenting the results of the sliding neck screw of the DHS in 1955 [5]. Here any force acting on the femoral head in the direction of the body axis will be diverted by the sliding neck screw into the direction of the axis of the screw, so that it strikes the fracture line approximately at a right angle and acts not as a shearing but as a compressing force stimulating callus formation. Here too varus collapse, shortening, superior cut-out occurred. But in non-union was rare.

What is an unstable intertrochanteric fracture?
Stable intertrochanteric fracture implies that the reduction is stable with a lesser tendency to collapse further post-operatively. Whereas the unstable IT fractures have a tendency to collapse much more post-operatively, especially in varus and retroversion. Fractures with a large posteromedial void, reverse oblique fracture configuration, IT fractures with subtrochanteric extension and IT fractures with a lateral wall fracture [6-10].
Modifications of DHS:
Two major modifications to the DHS are the Medoff’s plate and the DHS with a trochanteric stabilisation plate.
In 1991, Medoff et al used a new axial compression screw plate device for unstable intertrochanteric or proximal subtrochanteric fractures of the hip with no technical failures [11]. The device has an axial compression screw to allow compression along an axis parallel to the femoral shaft. As the fracture settles postoperatively, dynamic axial compression continues. In 1993, Babst et al. stated that the lateralisation of the greater trochanter could be prevented in all cases with a trochanteric buttress plate being added to the sliding screw-plate [12]. This also leads to a limitation of telescoping, with less shortening even with immediate full weight bearing. Leung F et al concluded that the DHS blade plate was an effective fixation option in elderly osteoporotic patients with intertrochanteric fracture femur where the conventional lag screw was replaced with a helical blade [13]. Here, the helical blade leads to better blade fixation in osteorotic bone by impaction of the cancellous bone while insertion rather than destroying bone while reaming for the DHS lag screw.

Other conventional options:
95 degree DCS or angle blade plate is often used to treat the reverse oblique intertrochanteric fractures as they biomechanically mimic the subtrochanteric fractures. Rosso R et al recommend that the DCS may be used to treat subtrochanteric fractures rather than intertrochanteric fractures [14].

Era of Intramedullary nails:
Gamma Nail:
This was one of the earliest intra-medullary (IM) imlants to be designed in 1988. The premise on which the IM implants were designed were:
1. To reduce the varus strain on the implant while weight bearing by reducing the force arm.
2. To provide a lateral buttress with an IM device to prevent the lateralization of the proximal fragment and control the collapse rather than relying on the integrity of the lateral wall.
Bridle et al in 1991, prospectively compared the dynamic hip screw and the gamma nail in100 intertrochanteric fractures in elderly patients [15]. They found no difference in the operating time, blood loss, wound complications, and stay in hospital or the patient’s mobility. But fractures of the femur in 4 cases were seen in the gamma nail group which required further revision surgery.
Leung KS et al in 1992conducted a randomized study in elderly patients comparing gamma nails and dynamic hip screws and concluded similar final outcome with both, but achieved less surgical trauma, less screening time, less blood loss and earlier rehabilitation with gamma nails [16].
Radford PJ et al prospectively compared the Dynamic hip screw and the Gamma nail for fixing 200 peritrochanteric femoral fractures in elderly patients [17]. There was less intraoperative blood loss and a lower rate of wound complications in the patients treated by the Gamma nail. They however had a high incidence of femoral shaft fractures which were related to the implant design. They did not recommend the use of the Gamma nail for these fractures. Curtis MJ in 1994 assessed the rigidity and strength of fixation provided by intramedullary and extramedullar devices for proximal femoral fractures [18]. Stable and unstable intertrochanteric fractures were studied after fixation with Gamma nail and DHS implants. There was no significant difference in the strength of fixation of stable and unstable intertrochanteric fractures between the Gamma nail and the hip screw, although the Gamma nail provided more rigid fixation. In 2001, Adams CI et al prospectively compared the IM nailing with a DHS and side plate in 400 patients [19]. Revision rates, femoral shaft fractures, and lag screw cutout were slightly higher in the IM nailing group but not statistically significant from the DHS cohort. There was no difference in the early or 1 –year functional outcomes. Ahrengart L et al randomized 426 intertrochanteric fractures to be fixed with either the Gamma nail or a compression hip screw [20]. The surgical time was not significantly different between the two groups. In the Gamma nail group, difficulty was encountered with the distal locking technique. The incidence of cephalic position of the compression screw within the femoral head, screw cutout, and intraoperative fracture were higher in the Gamma nail group. Walking ability was the same in both groups. The authors recommended compression hip screws for less comminuted fractures, reserving Gamma nails for comminuted patterns.
Utrilla AL et al compared the Gamma nail with a compression hip screw in 210 stable and unstable fractures and found no difference in total surgical time [21]. However, the Gamma nail group had a significantly lower postoperative transfusion requirement. Mortality, fracture healing, and intra- and postoperative complication rates were not significantly different between the two groups. In patients with unstable fracture patterns, postoperative ambulation was significantly improved in the Gamma nail group.

Newer Gamma nails:
The Preference to the use of Gamma nail for unstable IT fractures after early 2000 was primarily due to the introduction of second generation Gamma nail called the Trochanteric Gamma Nail (TGN) and the third generation Gamma nail called the Gamma3 Nail (G3). Better implant design led to decreased fracture shaft femur, which was the complication seen in early generation Gamma Nail [22].
The G3 proximal diameter is 15.5 mm, 1.5 mm smaller than TGN (17 mm). G3 design also allows distal dynamic locking screw. But the migration resistance in G3 is lesser than TGN. The main reason for this is the smaller diameter in the G3 lag screw measuring 10.5 mm rather than 12 mm in the TGN [22].
The latest edition to the G3 design is the Gamma3Rotational Control, with the addition of a spreading U-Clip over the cephalic screw which increases the surface area and also the resistance to failure [22].
Clinical studies report better results with G3. Varela-Egocheaga JR et al reported 2 cases of cutout and 1 screw protrusion in 40 patients (7.5%) in a series comparing G3 with an extramedullary device [23]. Andruszkow H et al reported that a TAD should not exceed 25mm and a valgus reduction reduces the chances of screw cut-out [24]. de Grave PW et al [25] reported 2 cases of mechanical failure in 61 patients treated with a Gamma3 nail, and Westacott D and Bould M [26] reported no case of mechanical failure in 36 unstable proximal femoral fractures treated with a long Gamma3 nail. Mingo-Robinet J et al stated that there was no relationship between cutout rate and TAD in TGN and G3 [22]. Though they concluded that Gamma3 Nail has higher cutout rates than TGN in unstable fractures.

Proximal Femoral Nail
In 1996, AO/ASIF developed the proximal femoral nail (PFN) as an intramedullary device for the treatment of unstable per, inter and subtrochanteric femoral fractures.
Pajarinen J et al compared the DHS with a proximal femoral nail (PFN) in 108 patients and the main outcome measure was recovery of ambulation [27]. The patients treated with IM devices had a significantly faster return to preoperative ambulation levels. Nuber S et al evaluated 129 patients with unstable intertrochanteric fractures treated with either a DHS or a PFN [28]. Revision rates were similar between the two groups. However, there was a significantly shorter surgical time, shorter hospital stay, earlier full weight bearing and lesser pain intensity at 6-months post-op in the PFN cohort. Zhang K et al stated in a meta-analysis of six studies including 669 intertrochanteric fractures that the PFN group had significantly less operative time, intraoperative blood loss and length of incision than the DHS group [29]. There was no significant difference in the postoperative infection rate, lag screw cut-out rate, or reoperation rate between the PFN and DHS groups. They concluded stating that PFN is a better implant than DHS.

Newer PFN designs
PFNA-II is the modified PFN design meant to match the Asian proximal femoral morphometry. Expandable PFN was designed to retain the mechanical characteristics of a large-diameter nail, to provide the good torsional stability between the femoral neck and shaft obtained by an expendable peg inserted in the femoral head (especially in cases of poor bone quality), and to avoid the need for interlocking screws. However its long term utility needs further literature support. Elis J et al concluded that the expandable PFN was at least as good as the 95 degree DCS after comparing the EPFN and the 95 degree DCS [30]. Jin YM et al concluded that expandable PFN are better implants than DHS and anatomic plates in treating intertrochanteric fractures [31].

InterTAN
This is a newer intra-medullary fixation device which uses proximal intergrated interlocking screws in a figure of eight position to attain compression of the intertrochanteric fracture site.
Wang Q et al compared the InterTAN and the DHS and concluded that InterTAN significantly reduces the operative time, intra-operative radiation exposure, intra-operative blood loss and postoperative complications [32]. The InterTAN can be used in elderly osteoporotic patients and in and unstable intertrochanteric fractures.
Jiang Y et al stated that a proper pre-operative imaging, reaming is essential before inserting the InterTAN [33]. But an open reduction and internal fixation with DHS be preferred in cases where the reduction is difficult.
Nüchtern JV et al concluded that the InterTAN with two integrated screws was able to withstand higher loads than the Gamma 3 nail [34].

Newer Proximal femoral Locking plates:
Many new designs of proximal femoral locking plates have been used to treat intertrochanteric fractures. But there is not enough literature evidence of they being better than IM implants. Haq RU et al concluded that PFN is a better implant than reverse-distal femoral locking plate for intertrochanteric fractures with a deficient lateral wall [35]. Zhong B et al stated that the proximal femoral locking plates were better for treating subtrochanteric fractures rather than intertrochanteric fractures [36].
Azboy I et al concluded that both proximal femoral locking plate and 95 degree angle blade plate gave equally good results in reverse oblique intertrochanteric fractures. However, angle blade plates were preferred as they were an economical option [37].
Dhamangaonkar AC et al compared the Proximal femoral locking plate with the DHS. They concluded that proximal femoral locking plates decreased the chances of limb shortening and medialisation of the shaft [38].
A recent study by Shen J et al concluded that these plates are an effective and safe method in the treatment of all types of intertrochanteric femoral fractures, but good fracture reduction and ideal positioning of the neck screw are prerequisites for the success of the device [39].

Hemiarthroplasty
Prosthetic hip replacement generally has not been considered a primary treatment option for intertrochanteric fractures. In this setting, prosthetic replacement for intertrochanteric fractures typically requires a more complex surgical procedure to reconstruct the calcar and trochanters with potentially higher morbidity. In the patient with preexisting symptomatic degenerative arthritis and in extremely comminuted osteoporotic intertrochanteric fractures, primary prosthetic replacement may be a better option [40].
Kim Y et al studied 143 hips in 139 octagenarians who underwent a cementless bipolar hemiarthroplasty for intertrochanteric fractures concluded that cementless bipolar hemiarthroplasty appears to be a suitable method for the treatment of intertrochanteric fracture in octogenarians [41]. And recommended that stable fixation of the posteromedial fragment is necessary to avoid stem subsidence. Emami M et al studied 60 patients with IT fractures, compared bipolar hemiarthroplasty and DHS fixation and concluded that in elderly patients with co-morbidities, bipolar hemiarthroplasty was more effective than DHS with better functional status, however there was no difference in pain severity between the two groups [42]. Cankaya D et al compared the functional outcome of cementless versus cemented hemiarthroplasty in 86 elderly patients and concluded that cementless hemiarthroplasty was better in terms of duration of surgery, amount of blood loss and perioperative mortality rates than in the cemented group [43]. But Shen J et al categorically stated after studying 124 patients above 70 years of age, that Internal fixation is preferred as it leads to a higher Harris scores, lesser pain, and better walking ability than those treated with hemiarthroplasty provided there is good and stable reduction, even when severe osteoporosis is present [44]. Tang P et al, after retrospectively studying 303 patients concluded that PFNA was superior to hemiarthroplasty according to the operative statistics, especially the anaesthesia, operation lasting time, blood loss, blood transfusion and the drainage, but there were no significant differences in functional outcome [45]. But the incidences of complications were higher in hemiarthroplasty group. Hemiarthroplasty may still find favor in cases with fracture comminution in elderly with severe osteoporosis or in cases with failed fixation of intertrochanteric fracture [46]. More definative evidence will be needed to stratify the patients who would be benefitted by hemiarthroplasty.

Treatment Algorithm
The American Academy of Orthopaedic Surgeons (AAOS) presented a Clinical Practice Guidelines (CPG) on the management of hip fractures after reviewing above16,000 abstracts and above 1700 full-text articles and came out with 25 evidence-based recommendations. We present here a summary of the same [47].
Apart from the operative decision, the recommendations do suggest important practices like avoiding delays to surgery, decreasing delirium, initiate postoperative physical therapy, nutritional, calcium and vitamin D supplementation and evaluation of osteoporosis.
The next important determinant affecting the operative plan, is the IT fracture configuration- whether stable or unstable. There is equal evidence for the use of either intramedullary implants or sliding hip screws in the treatment of stable intertrochanteric fractures. Though the newer generation orthopaedic surgeonsprefer the use of IM implants due to its percutaneous insertion, lesser operative time and blood loss. Though, the cost of implant, comfort and training of the surgeon determines the choice of implants.
There a strong recommendation to use the IM implants for the unstable IT fractures, especially the ones with a subtrochanteric extension and reverse oblique fracture configuration. There is however not enough literature to suggest use of short or long IM implants and further studies are required to determine the outcome of each.

Clinical Relevance

The most important determinant of treatment of IT fractures is whether the fracture is stable or unstable and advantages of the newer implant designs available to treat IT fractures. Stable fractures may be fixed with either intra-medullary or extra-medullary implants. The treatment of unstable IT fractures needs meticulous pre-operative planning, good intra-operative reduction and use of intra-medullary implants. The surgeon is free to use any design amongst the many intra-medullary implants as per the training and experience of the surgeon. There is as yet no consensus in literature regarding whether to use short or long IM nails. As far as possible fixation of IT fractures is to be attempted rather than a hemiarthroplasty.

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How to Cite this article: Dhamangaonkar AC. Management Options and Treatment Algorithm in Intertrochanteric Fractures. Trauma International July-Sep 2015;1(1):12-16.

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How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

Management Options and Treatment Algorithm in Intertrochanteric Fractures

How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

Management Options and Treatment Algorithm in Intertrochanteric Fractures

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How to Avoid local Complications during Primary and Revision surgery of Trochanteric fractures: Advices and Tricks for operation tactics and Trouble-shooting

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Management Options and Treatment Algorithm in Intertrochanteric Fractures

Author: Anoop C Dhamangaonkar [1].

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